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Botox didn't work: what now

Published 13 March 2026 ·Last reviewed 13 March 2026 by the editorial team ·How we create our content

At a glance

When botox does not heal a fissure, it is disappointing but not unusual — botox works for roughly 50 to 70 percent of people. This guide covers what the options are from here, why botox may not have worked, and how to approach the next conversation with your surgeon.

Understanding why

Botox may not heal a fissure for several reasons:

  • Insufficient sphincter relaxation — the dose or injection site may not have adequately relaxed the muscle
  • Very high sphincter pressure — some people have resting pressure that is too high for botox alone to address
  • Chronic fissure features — deep scarring, fibrosis, or poor blood supply in the fissure bed that prevents healing even with adequate relaxation
  • The fissure healed but recurred — the botox wore off before the healing was complete or permanent

Importantly, botox not working does not mean the fissure is untreatable. It means a different approach is needed.

The options

Second botox injection

Appropriate when:

  • The first injection provided partial improvement
  • The fissure healed but recurred after the botox wore off
  • The surgeon believes a different dose or technique may help

Not appropriate when:

  • The first injection provided no benefit at all
  • Two injections have already been tried

Lateral internal sphincterotomy (LIS)

The most effective surgical treatment for chronic fissures:

  • How it works: A small, controlled cut in the internal sphincter permanently reduces resting pressure
  • Success rate: Generally described as above 90 percent for chronic fissures
  • Recovery: One to two weeks off work for most people; full healing over four to eight weeks
  • Risk: A small risk of changes in gas or stool control. Your surgeon will discuss this in detail.

LIS is typically the next recommendation when botox has failed.

Fissurectomy

Removal of the chronic fissure tissue, sometimes combined with botox or a sphincterotomy:

  • How it works: The scar tissue and chronic fissure bed are excised, creating a fresh wound that can heal normally
  • When it is chosen: When the fissure has significant scar tissue, a large sentinel pile, or when combined with other approaches
  • Recovery: Similar to LIS, though the open wound takes longer to heal

Continued conservative care

In some cases — particularly if the fissure is not severely symptomatic — people choose to continue managing with dietary measures and topical treatments rather than proceeding to surgery. This is a valid choice, particularly if quality of life is acceptable with management.

The conversation with your surgeon

Questions worth asking:

  • Why do you think botox did not work in my case?
  • Do you recommend a second injection or surgery?
  • If surgery, which procedure and why?
  • What is the specific success rate for my situation?
  • What are the risks, particularly regarding continence?
  • What is the recovery timeline?

Moving forward

The progression from conservative treatment to botox to surgery is a standard treatment pathway. Each step provides information about what the fissure needs. Reaching the point of considering surgery does not represent a failure — it represents a thorough approach that has narrowed down the right treatment.

Common questions

Why does botox not work for some people?

Several factors can contribute: the dose may not have been sufficient for your sphincter, the injection site may not have targeted the area of spasm effectively, the sphincter pressure may be too high for botox alone to overcome, or the fissure may have developed features (deep scarring, poor blood supply) that prevent healing even with adequate sphincter relaxation. In some cases, the cause is unclear.

Should I try a second botox injection?

This depends on how you responded to the first. If there was partial improvement — some reduction in pain and spasm but not enough for complete healing — a second injection may provide the additional benefit needed. If there was no improvement at all, most surgeons will discuss surgery rather than repeating the same approach.

What surgical options are there after botox fails?

The main surgical options are lateral internal sphincterotomy (LIS), which has the highest healing rate, and fissurectomy (sometimes combined with botox). LIS permanently reduces sphincter pressure. Fissurectomy removes the chronic fissure tissue. Your surgeon will discuss which is most appropriate for your specific situation.

Does botox failing mean surgery will not work either?

No. Botox and surgery work differently. Botox provides temporary, partial sphincter relaxation. LIS surgery provides permanent, more complete reduction in sphincter pressure. Many people whose fissures did not respond to botox go on to heal successfully after surgery. The healing rates for LIS are generally above 90 percent.

When to seek care Heavy bleeding or feeling faint? Get emergency help now. Emergency: 911

Not sure how urgent it is? Get help today.

  1. Emergency

    Heavy bleeding, black tarry stools, feeling faint, severe pain or trouble breathing.

    Call 911 or go to the ER.

  2. Today

    Fever, pain getting worse, a hot swollen lump, or trouble passing urine.

    Call your doctor or go to urgent care.

  3. Soon

    Bleeding or bowel changes nobody has checked, or anything lasting 3 weeks.

    Book a doctor’s appointment.

Feeling overwhelmed? Call or text 988, any time.

See all the signs

For this topic, get medical advice if you notice:

  • Heavy or persistent bleeding that does not settle
  • Severe pain that is getting worse rather than better
  • Fever or signs of infection
  • Symptoms that have not improved after 4 to 6 weeks of self-care

Recording how you feel is not the same as being checked. These are the signs that need a doctor’s attention.

Call 911 or go to the emergency room now if you have:

  • bleeding that will not stop, a lot of blood (the toilet water turns red, or you pass large clots), or any bleeding with feeling faint or dizzy
  • fainting, a racing heart or trouble breathing
  • confusion or slurred speech, extreme shivering, no urine in a day, or blotchy skin
  • sudden severe belly pain, or a swollen, hard belly with vomiting or not passing stool or gas
  • you cannot pass urine at all, or your bladder feels full and painful and you can’t empty it
  • redness, swelling or severe pain spreading quickly around your anus, genitals or groin, especially with a fever or feeling very ill
  • a fever with a painful swelling near your anus if you have diabetes or a weakened immune system (for example, from chemotherapy or transplant medicines)
  • black, tarry stools

Call your doctor or go to urgent care today (or the ER if you can’t be seen today) if you have:

  • a temperature of 100.4°F (38°C) or higher, chills, vomiting, or feeling generally unwell
  • pain that is getting worse over days, or severe pain that stops you sitting or sleeping
  • a hot, swollen or very tender lump near your anus or at the top of the crease between your buttocks, or foul-smelling discharge
  • trouble urinating
  • bleeding that is getting heavier or more frequent, or blood mixed into your stool
  • feeling much more tired than usual, looking pale, or getting out of breath more easily than you used to
  • not passing stool for several days, or new belly pain

Make an appointment with your doctor if:

  • you have never had these symptoms checked by a doctor or nurse — whatever your age
  • you have had rectal bleeding for more than 3 weeks
  • your bowel movements have been looser, thinner or more frequent than usual for 3 weeks or more, or you have lost weight without trying
  • symptoms have not settled after a week or so, or keep coming back
  • you notice a new lump near your anus, between your buttocks or in your belly, or an itch or discharge that does not clear
  • you have new leakage or trouble controlling your bowels
  • you are 45 or over, or have a family history of bowel cancer or inflammatory bowel disease, and any of these symptoms are new for you

If you are unsure, it is always reasonable to ask. If things feel overwhelming, call or text 988 (Suicide & Crisis Lifeline) or chat at 988lifeline.org, any time. If you don’t feel safe, call 911.

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Related symptoms

BleedingPain during bowel movementsPain after bowel movementsSpasm or crampingConstipation

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When fissure botox does not work

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